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HomeMy WebLinkAbout8632AQ U m WORKERS' COMPENSATION DECLARATION I hereby affirm, that I have a certificate of consent to self insure, or a certificate of Workers' Compenstion Insurance, or a certified copy thereof (Sec. 3800, Lab. C. ) Policy No. C1 _Company Mission Ins. CO. (D Certified copy is hereby furnished. Certified copy is filed with the county building inspec- tion department. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for.one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Number 317237 Lic. Class 13^1 Contractor Carlsberg Const.Date 6429181 ❑ I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer acting in my professional capacity (Section 7051, Business and Professions Code). Lic, or Reg. No, --Date OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Code): I, as owner of the property, or my employees with wages as their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name Bank of California Lender's Address 550 S. Flower, T,. A. CA 90017 I certify that I have read this application and state that the above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter upon the above -mention d eropert for inspection jourposts. Signature of Applicant or A nt Dote A PPICA i.�n k 4 Sty S ^'r FOR BUILDING PERMIT • i • re�,ANqflS BUILDING AND SAFETY • FOR APPLICANT TO FILL IN ADDRESS �� / �/}Le> ie BUILDING �.L: ADDRESS LOCALITY (s x ,-c_. mac x= CITY Diamond B r CA ZIP 9 765 NEAREST CROSS ST. one o NO. OF BLDGS. ASSESSOR SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL TRACT BLOCK LOT NO. USE ZONE NO. f� TEL. 2 '3 SPECIAL OWNER NO. _ Lu CONDITIONS DISTRICT GROUPTCONST. PE FIRE PROCESSED BY ADDRESS 2800 28th Street ZONE O CITY Santa, Monica, CA zip 90405 ARCHITECT OR TEL, STATISTICAL CLASSIFICATION APT. CONDO. ENGINEER PasadenaDesign _ 1 L t CLASS NO DWELL UNITS " ADDRESS1041 E. Green St. PaS dena CA SEWER MAP BK. PG, VALIDATION VALUATION $ 296,400 2 g 6 32 A CONTRACTOR CarlsbergConst. NO. 4 0-6800 LIC. ADDRESS 2800 28th Street NO. 317237 LIC. CITY Santa, Monica, CA CLASS B-1 SQ. FT. NO. OF NO. OF CHECK SIZE STORIES FAMILIES ONE �✓ p , o,861,60 DESCRIPTION OF WORK NEW ® wood frame townhouses ADD ❑ FINAL m• j 6 1, 6 0 -chi ALTER ❑ _ r i DATE USE OF u NAL .EXISTING BLDG, N/A DEMOL By APPLICANT TEL. Y (PRINT) ('arl [harrr (nrie+ r'nNn aSn_rA00 NG' SS ITY G TEL j��� n , I✓ (�� (� ACTOR NO. G� SS IRED kRE YARD HWY TOTAL SETBACK FROM EXIST. ACK PROP. LINE WIDTH NTe $ 1 : �r-a� Perm�Fee�© " Issuance Fee Investigation Fee Total Fee ✓•� l'd SEE REVERSE FOR EXPLANATORY LANGUAGE 0'/,06--8 1 ©s